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\begin{document}

\title{Surgical technique for acute retrograde type A aortic dissection after
zone 2 TEVAR for complicated type B dissection in a 63 year old patient}



\author[1]{Paulus Schurr}%
\author[1]{Mohamed Morjan}%
\author[2]{Peter Fellmer}%
\author[1]{Jochen Boergermann}%
\affil[1]{Herzzentrum Duisburg}%
\affil[2]{Evangelisches Klinikum Niederrhein gGmbH}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\selectlanguage{english}
\begin{abstract}
Patients suffering retrograde type A dissection after TEVAR for type B
dissection are at a higher risk of mortality than their spontanous
counterparts and the kind of optimal therapy remains obscure. We present
a rare case of successful open surgical repair where distal open
anastomosis was accomplished cutting off the un-covered stent portion
and suturing a vascular prosthesis to the dissected distal aortic arch
including the covered stent part. The clinical course was regular.
Immediate and radical repair in the aortic arch may be the adequate
response in such instances.%
\end{abstract}%



\sloppy


\emph{Title:}

Surgical technique for acute retrograde type A aortic dissection after
zone 2 TEVAR for complicated type B dissection in a 63 year old patient

\emph{Short title:}

Retrograde type A after type B dissection

\emph{Authors:}

Paulus Schurr\textsuperscript{1}, Mohamed Morjan\textsuperscript{1},
Peter Fellmer\textsuperscript{2} and Jochen
B\selectlanguage{ngerman}örgermann\textsuperscript{1}

\emph{Affiliations:}

\textsuperscript{1}Clinic for Heart Surgery and\textsuperscript{2}Clinic
for Vascular Surgery at the Heart Center of Evangelisches Klinikum
Niederrhein, Gerrickstrasse 21, 47137 Duisburg, Germany.

\emph{Correspondance to:}

Paulus Schurr, Clinic for Heart Surgery, Gerrickstrasse 21, 47137
Duisburg, Germany. Phone: +49 203 451 3251, Fax: 0203 451 3258. Email:
paulusschurr@live.com

\emph{Patient consent:} The patient gave written consent to publication
of clinical case details and images.

\emph{Abstract:}

Patients suffering retrograde type A dissection after TEVAR for type B
dissection are at a higher risk of mortality than their spontanous
counterparts and the kind of optimal therapy remains obscure. We present
a rare case of successful open surgical repair where distal open
anastomosis was accomplished cutting off the un-covered stent portion
and suturing a vascular prosthesis to the dissected distal aortic arch
including the covered stent part. The clinical course was regular.
Immediate and radical repair in the aortic arch may be the adequate
response in such instances.

\emph{Key words:}

Retrograde type A dissection, TEVAR, type B dissection

\emph{Conflict of interest statement:}

All authors disclose any potential conflict of interest.

\emph{Text:}

Patients developing retrograde acute type A dissection after TEVAR for
complicated type B dissection display higher morbidity and mortality
than in spontanous acute type A dissection.\textsuperscript{1} The kind
of optimal therapy remains obscure and both open versus interventional
angiographic repair may be considered. In cases of pericardial tamponade
open surgery may solve the problem. We present a case of successful open
surgical repair including total replacement of the aortic valve, root,
ascending aorta and arch until zone 2. In this particular instance, the
distal open anastomosis was accomplished by cutting off the un-covered
stent portion protruding into zone 0, and by suturing a vascular
prosthesis to the dissected distal aortic arch including the covered
stent part into the stitches.

Case presentation: At the time of acute complicated type-B dissection,
urgent debranching by a left carotideo-subclavian bypass and zone 2
TEVAR using two Cook\selectlanguage{english} stentgrafts (one tapered 40-36 mm, one straight 36
mm) were performed. Procedural success was documented by CT scan showing
false lumen thrombosis and the patient discharged without any complaints
thereafter. Three weeks later the patient presented to the hospital with
severe chest pain and a CT scan was immediately obtained. Acute
retrograde type A dissection was diagnosed involving the aortic root,
the ascending aorta and the arch. (Figure 1) Rapidly, the patient
developed high-grade aortic insufficiency and pericardial tamponade and
was immediately sent for surgery.

A valve-replacing full root replacement using a stentless all-biological
graft (BioIntegral\selectlanguage{english} 25 mm) and an ascending and total arch replacement
(Hemashield\selectlanguage{english} vascular graft 28 mm) were performed. Two supra-aortic arch
vessels were reimplanted together (brachiocephalic trunk, left common
carotid) using a common island technique. Distal open anastomosis was
accomplished in zone 2 after resecting the bare metal ends of the stent
graft using scissors. By a double 3-0 prolene running suture the Dacron
graft was connected to the distal arch including the covered portion of
the stent. The drawing illustrates the suturing technique (Figure 2).
After an uneventful course the patient was discharged and recovered
fully. Postoperative CT imaging one week, 6 and 11 months after surgery
shows a stable procedural success. (Figure 3) Follow-up echocardiography
showed a regular valve function. Meanwhile, the patient has returned to
work and resumed driving motorcycle.

Discussion: Retrograde type A dissection after TEVAR occurs at 2.5\% and
frequency is higher in patients following TEVAR for type B dissection
compared to aneurysm repair.\textsuperscript{1} Mortality remains a
major issue, with values ranging from 37 to 50\%.
\textsuperscript{2}When bail-out re-do TEVAR in the arch is not
feasible, open repair becomes necessary. No recommendations with respect
to anastomotic technique in the arch have been made so far, but it can
principally either include removal of the TEVAR stent graft from the
native aorta or its preservation within. In cases with bare metal ends
extending to the proximal arch, an anastomotic suture problem exists. In
the present case, cutting off the bare metal ends and including the
covered stent part into the suture line resulted in excellent
hemostasis. Follow-up in similar cases and scientific reporting is
desirable.

Patient consent: The patient gave written consent to publication of
clinical case details and images.

Figure legend:

Figure 1: CT showing the thrombosed false lumen*, the acute retrograde
type A dissection** and the aortic root (AR). Angulation: LAO 64deg.

Figure 2: Scheme of anastomotic suturing technique.

Figure 3: Postoperative CT scan 11 months after surgery showing the
anastomosis* and aortic root (AR). Angulation: LAO 58deg.

1. Chen Y, Zhang S, Liu L, Lu Q, Zhang T, Jing Z. Retrograde Type A
Aortic Dissection After Thoracic Endovascular Aortic Repair: A
Systematic Review and Meta-Analysis. \emph{J Am Heart Assoc.} 2017;6(9).

2. Yammine H, Briggs CS, Stanley GA, et al. Retrograde type A dissection
after thoracic endovascular aortic repair for type B aortic
dissection.\emph{J Vasc Surg.} 2019;69(1):24-33.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1-retrogr-TAAD-after-TEVAR-2022-04-02/Figure-1-retrogr-TAAD-after-TEVAR-2022-04-02}

\end{center}
\end{figure}\selectlanguage{english}
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\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3-retrogr-TAAD-after-TEVAR-2022-04-02/Figure-3-retrogr-TAAD-after-TEVAR-2022-04-02}

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\end{figure}\selectlanguage{english}
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\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2-retrogr-TAAD-after-TEVAR-2022-04-02/Figure-2-retrogr-TAAD-after-TEVAR-2022-04-02}

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\end{figure}

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